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This post is an answer to the ECG Case 261

• Rate: ~84 bpm
• Rhythm: Regular
• Axis: RAD
• Intervals:
  • PR – Prolonged(~220ms)
  • QRS – Normal (80-100ms)
  • QT – 400ms (QTc Bazette 470-480 ms)
• Segments:
  • ST Elevation in leads II, III, aVF, V4, V6
    • Unusual ST morphology in inferior leads
  • ST depression in lead aVL, V1-3

• Additional:
  • Note complete lead inversion leads I, aVL – negative P/QRS/T

Interpretation

• STEMI
• Lead malposition
  • Likely V4 and V5 reversed
  • RA / LA limb lead reversal resultant inversion lead I, II/III switched and aVR/aVL switched

What happened ?

The patient was taken for urgent PCI which was normal ! He subsequently went on to have a CT brain which showed an extensive sub-arachnoid haemorrhage.

There are a number of cases in the literature were sub-arachnoid hemorrhage has been associated with significant ST changes.